Working For Tips…

Sonya Pease, MD, MMSC
Chief Medical Officer, TeamHealth Anesthesia, Palm Beach Gardens, FL

Date night with my husband usually involves going out to one of our favorite restaurants where we get to enjoy each other’s company in a relaxed atmosphere without worrying about who’s doing the dishes. So how can a night out at a restaurant have anything in common with having a total joint replacement?

My husband and I feel that every waiter or waitress generally deserves a 20 percent tip. From the time we get seated at the table to the time we pay the tab, my husband and I are unconsciously measuring both the restaurant’s and the servers’ performance and quality. We are not concerned about the fact that our waitress has to go to the bar for our glasses of wine or that the bartender may be busy serving happy hour drinks; we just want our drinks timely and exactly as we ordered. Same goes for the food we order. We don’t care that the appetizer kitchen is backed up or that the kitchen crew is trying to perform miracles by having the seared Ahi and well-done steak come out at the same time from two different grills. We expect the restaurant and our server to coordinate all of this seamlessly in the background so our food arrives together, is served hot and tastes great. If our server forgot to put the salad dressing on the side or the steak was undercooked, then we simply note our dissatisfaction with the poor quality and unmet expectations by giving a lower tip. Restaurants with fantastic quality and service thrive while those with poor quality and service don’t.

We have all entered into this brave new world of healthcare with its focus on the triple aim of increasing patient satisfaction, improving patient outcomes and reducing costs. Getting paid to perform a service as a physician used to be fairly straightforward. The Current Procedural Terminology® (CPT) manual designated the service we provided, and the Relative Value Guide® (RVG) furnished the base units for providing that service. Simple! It didn’t really matter if the service we provided didn’t benefit the patient or if the patient developed a complication—we still got paid the same for the service we provided.

But now the Centers for Medicare and Medicaid Services (CMS), the largest health insurer in the United States, has begun to measure the quality as well as the level of service we provide to our patients. The Physician Quality Reporting System (PQRS) has now become mandatory, and penalties for not reporting are on the horizon. PQRS measures are predominantly process measures shown to correlate with improved clinical outcomes, but these measures are not actual measures of outcomes. For example, we are getting graded on whether or not we properly documented administration of the antibiotics on time, not whether or not the patient developed a post-op wound infection. As time passes and these types of process measures change our practice, many will be retired since they no longer represent a gap in care or an opportunity for quality improvement. Therefore, these targets will continue to change.

We have also entered into the new era of Value-Based Purchasing (VBP). A new payment modifier that Section 3007 of the Affordable Care Act mandated states that, by 2015, CMS must begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS). Both cost and quality data are to be included in calculating payments for physicians. The VBP modifier is essentially a conversion factor applied to your payment, 25 percent weighted on outcomes, 45 percent based on process quality measures as mentioned above, and 30 percent on patient satisfaction as measured by Healthcare Consumer Assessment of Healthcare Providers and Services (HCAHPS). The look-back period for our 2015 VBP payment modifier of HCAHPS scores started in 2013.

So, just as our waitress or waiter get a lower tip when the quality of our food or the service provided does not meet our expectations, so will we as providers receive a lower payment if the quality of our care or the level of

Our challenge becomes how do we deliver seamlessly coordinated care where patients feel like they were treated with the utmost respect and given five-star service while, at the same time, improve outcomes, prevent complications and shorten length of stay to drive down costs?

For a lot of patients, it starts in the emergency department. We know that longer wait times cause patient dissatisfaction and lower HCAHPS scores. We also know that when a patient sees and is a part of a physician-to-physician or nurse-to-nurse handoff, these scores are positively impacted; so communication to the patient, about the patient, and to other caregivers is a major factor in patient satisfaction. A good waiter, for example, will introduce him/herself, keep you informed of delays (“I’m sorry the bread isn’t out yet—we’re baking a fresh batch so yours will be nice and warm”), and check back often enough to know you have everything you need to enjoy your meal. As physicians, this is a skill set most of us didn’t learn in residency but it is imperative we learn it and use it going forward.

Post-operative nausea and vomiting (PONV) and post-operative pain (POP) are not only major patient dissatisfiers as reflected in HCAHPS scores, but they also lead to additional costs. By implementing a multimodal PONV program and a multimodal pain program with acute regional pain blocks, we can have a profound impact on patient satisfaction, improve the quality of our care by preventing these complications and drive down cost. These are basic business skills required in all industries to be successful.

In the restaurant business it starts with acquiring quality ingredients for food prep. Unfortunately we don’t get to pick and choose our patients but we can make sure our patients are optimized prior to surgery and that we are implementing “best practices” in a uniform, more standardized fashion that reduces risks. A good example is anemia, an independent risk factor for all patients presenting for surgery but not routinely identified or treated prior to surgery. This increases the risk of blood transfusions which, in turn, increases cost and complication rates associated with those blood transfusions. By implementing a Patient Blood Management program and identifying and treating anemia pre-operatively we can have a profound impact on patient outcomes as well as costs.

Determining our future “gratuities” is easy as long as we take to heart Dairy Queen’s “Good isn’t good enough.” We must learn to look beyond excellent execution of the clinical task before us, and consider not only the impact on the immediate clinical outcomes, but also the impact of our “customers’” perception of care on our financial outcomes for our own group as well as for our hospital partner.

References:

• Effect of a PBM programme on the preoperative anaemia, transfusion rate, and outcome after primary hip or knee arthoplasty: a quality improvement cycle. A. Kotze, L.A. Carter and A. J. Scally. Rao SV, et al. JAMA 2004; 292; 1555-62
• National Quality Forum (NQF), Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination: A Consensus Report, Washington, DC: NQF; 2010.
• Sentinel event data: root causes by event type 2004-2012. The Joint Commission Web site.
• http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_04_4Q2012.pdf. Published February 7, 2013. Accessed September 6, 2013.
• Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008; 34(10):563-570D
• Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia Guidelines for Management of Postoperative Nausea and Vomiting. Anesth Analg 2007; 105:1615
• Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting. Anesthesiology 1999; 91:693–700.
• The Economic Implications of a Multimodal Analgesia Regimen for Patients Undergoing Major Orthopedic Surgery A Comparative Study of Direct Costs
• Christopher M. Duncan, MD,* Kirsten Hall Long, PhD,Þ David O. Warner, MD,* and James R. Hebl, MD*
• Post op pain stats: Apfelbaum, Gan et al. Anesthesia and Analgesia 2003.2 Warfield, et al, Anesthesiology 1193,3 and Gan, TJ ASRA 2012 abstract
• Readmission for same day surgery: Coley KC, et al, J. Clinical Anesthesia 2002;14:349-353
• Oderda G, Gan, TJ Poster 46th ASHP, December 4-8, 2011, New Orleans, LA.
• The economic Implications of a Multimodal Analgesic Regimen for patients undergoing major orthopedic surgery; Duncan,MD, ASRA 2009
• http://www.jointcommission.org/assets/1/18/General_Information_1995-2Q2013.pdf
• American Society of Anesthesiologists Task Force on Management of the Difficult Airway, Anesthesiology 1993; 78: 597–602. [Clinical Practice Guideline, Level of Evidence A]
• American Society of Anesthesiology. Statement on Documentation of Anesthesia Care. Approved October 22, 2008. [Clinical Practice Guideline, Level of Evidence A]

Sonya Pease, MD, MMSC has served as CMO of TeamHealth Anesthesia since 2008 and has been a diplomate of the ABA since 1998. She received her Masters of Medical Science in Anesthesiology from Emory University and an M.D. with high honors from the Medical College of Georgia. She completed her residency in anesthesiology at the Jackson Memorial Medical Center in Miami and remains a clinically active anesthesiologist. She is a past president of the Florida Society of Anesthesiologists and serves on several national committees with the American Society of Anesthesiologists (ASA). Dr. Pease helped develop and implement the anesthesia quality outcome database used within TeamHealth Anesthesia nationwide called “Optimetrix”. Optimetrix drives quality improvement through actionable data that is protected within TeamHealth’s Patient Safety Organization (PSO). Dr. Pease is very engaged in the ASA’s work to develop the Perioperative Surgical Home model, a model of healthcare focused on the perioperative patient to improve quality, patient satisfaction and reduce healthcare costs. She can be contacted at spease@teamhealth.com.